The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Platelet count. A positive guaiac test of stool indicates the presence of occult (hidden) blood in the stool, which could be a sign of gastrointestinal bleeding. Platelet count is crucial in assessing for bleeding disorders or conditions that could lead to gastrointestinal bleeding. Platelets are essential for blood clotting, and a low platelet count could result in prolonged bleeding. Option A) Glucose is not directly related to the positive guaiac test result. Elevated glucose levels would be more indicative of diabetes. Option C) White blood cell count is not typically associated with a positive guaiac test result. White blood cells are more indicative of infection or inflammation. Option D) Amylase is an enzyme involved in the digestion of carbohydrates and is not directly related to occult blood in the stool. Educationally, understanding the rationale behind the need to review platelet count in this case reinforces the importance of interpreting laboratory results in a holistic manner. It also highlights the significance of recognizing the implications of abnormal findings, such as occult blood in the stool, and the need for further investigation to determine the underlying cause. This knowledge is crucial for nurses caring for pediatric patients to ensure timely and appropriate interventions for their well-being.

Correct Answer: B

Rationale: In this scenario, option B, "Gastroccult positive emesis," warrants immediate intervention by the nurse. This finding indicates the presence of blood in the vomitus, which could be a sign of gastrointestinal bleeding, a serious complication after a biliopancreatic diversion procedure. Prompt assessment and intervention are crucial to prevent further complications such as hypovolemic shock. Option A, "Strong foul-smelling flatus," is a common occurrence post-BDP due to changes in digestion but does not require immediate intervention as it is not indicative of a life-threatening condition. Option C, "Complaint of poor night vision," is unrelated to the client's current presentation of severe dehydration and is more likely associated with vitamin deficiencies common in patients post-BDP, but it does not require immediate intervention. Option D, "Loose bowel movements," can be expected after a BDP as a side effect of the procedure and dehydration but does not pose an immediate threat to the client's life. Educationally, this question highlights the importance of recognizing and prioritizing assessment findings that indicate potential life-threatening complications in patients with specific surgical histories. Understanding the postoperative complications of biliopancreatic diversion procedures and their associated signs and symptoms is crucial for nurses caring for these patients.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take first is to visualize the abdominal incision (Option C). This is important because the client's complaint of feeling like his insides spilled out when coughing could indicate dehiscence or evisceration of the surgical wound, which are serious complications requiring immediate attention. By visualizing the incision, the nurse can assess for any signs of wound disruption, such as separation of wound edges or protrusion of abdominal contents. Option A, notifying the healthcare provider, is not the first action to take in this situation because the nurse needs to assess the client's condition firsthand before escalating the issue. Option B, assuring the client that such feelings occur with wound infections, is incorrect as it overlooks the potential seriousness of the situation and delays necessary intervention. Option D, obtaining sterile towels soaked in saline, is also not the priority as it does not address the immediate need to assess the wound. Educationally, this question highlights the importance of prompt assessment and intervention in postoperative care, especially when complications such as wound dehiscence or evisceration are suspected. Nurses must be vigilant in monitoring surgical wounds for any signs of complications to prevent further harm to the client. This scenario underscores the critical role of nursing assessment in identifying and managing postoperative complications effectively.

Correct Answer: A

Rationale: In this scenario, the correct intervention is to administer opioid and non-opioid medication simultaneously (Option A). This approach is appropriate for managing severe pain effectively in a client with stage IV bone cancer. Opioids provide potent pain relief, while non-opioid medications such as NSAIDs or acetaminophen can complement their effects and improve overall pain management without solely relying on opioids, which may have limitations in severe cases. Option B, administering only opioid medication, may not provide adequate pain relief for severe pain, especially in a case like stage IV bone cancer where pain can be excruciating. Option C, encouraging relaxation techniques, is not sufficient to address severe pain in this context and may delay appropriate pain management. Option D, delaying medication administration until reassessment, is inappropriate as immediate pain relief is crucial for the client's well-being and comfort. Educationally, it is important for nurses to understand the principles of multimodal pain management, especially in cases of severe pain like in advanced cancer. By combining opioids with non-opioid medications, healthcare providers can optimize pain relief while minimizing potential opioid-related side effects, thus improving the overall quality of care for patients in pain.

Correct Answer: A

Rationale: In the context of a client with acute glomerulonephritis (AGN), the nurse should include the instruction to restrict sodium intake in the dietary guidelines. Sodium restriction is crucial in managing AGN because excessive sodium can lead to fluid retention and hypertension, which can further damage the already compromised kidneys in AGN. By limiting sodium intake, the client can help reduce fluid retention and manage blood pressure, thus supporting kidney function. Encouraging high-protein foods (option B) is not appropriate in AGN because excessive protein intake can increase the workload on the kidneys, potentially worsening the condition. Similarly, increasing potassium intake (option C) is not advisable as impaired kidney function in AGN can lead to hyperkalemia, making it important to monitor and potentially restrict potassium intake. Decreasing fluid intake (option D) may be necessary in some cases of AGN to manage fluid overload, but it is not the primary dietary guideline for this condition. In AGN, sodium restriction takes precedence over fluid restriction as excess sodium can contribute to fluid retention and hypertension, both of which can worsen kidney function. In an educational context, understanding the rationale behind dietary guidelines in specific conditions like AGN is crucial for nurses to provide effective patient care. By explaining the reasons behind dietary recommendations, nurses can empower clients to actively participate in their care and make informed choices to support their health outcomes.